WPSI Inpatient Clerk Online Application

Connect to Success Training Program Application - Inpatient Clerk

APPLICANT INFORMATION






You must reside in one of the following ZIP codes: 19104, 19131, 19139, 19143 or 19151


xxx-xxx-xxxx

MM/DD/YYYY

xxx-xx-xxxx



A criminal background does not exclude you from participation in this program.



If YES, you are not eligible for this program




DEMOGRAPHIC INFORMATION
Select all that apply. Use CTRL for multiple choices
PROFESSIONAL LICENSURE / CERTIFICATION 
LICENSE / CERTIFICATION 1




MM/DD/YYYY
LICENSE / CERTIFICATION 2




MM/DD/YYYY
EDUCATION
HIGH SCHOOL




MM/DD/YYYY

COLLEGE/UNIVERSITY




MM/DD/YYYY

GRADUATE WORK




MM/DD/YYYY

VOCATIONAL/TRADE SCHOOL




MM/DD/YYYY

EMPLOYMENT HISTORY

Please tell us about your employment history starting with your most recent position

Employer 1


xxx-xxx-xxxx



MM/DD/YYYY

MM/DD/YYYY






Employer 2


xxx-xxx-xxxx



MM/DD/YYYY

MM/DD/YYYY






ADDITIONAL QUALIFICATIONS

STATEMENT OF INTENT

DISCLAIMER AND SIGNATURE
I certify that my answers are true and complete to the best of my knowledge. If this application leads to entry into the program, I understand that false or misleading information in my application or interview may result in my release from the program.

Please enter your full name


Thank you for applying to University City District’s West Philadelphia Skills Initiative.
The application deadline is July 2, 2015.  

Incomplete applications will not be accepted.  Applications submitted with resumes will receive priority consideration.  Applications submitted after this date will be not accepted. This application is good for 30 days only.  Consideration for entry into subsequent programs require that a new application be submitted.

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